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In response to some of what I have recently written about the problems with too many medics, people have claimed that I don’t have any evidence to support my statements.[1],[2],[3]
This will cover just one of the many studies that demonstrate that less experience is bad for patients. For those who think that having all medic crews run all 911 calls, your problem will be burnout, since only a minority of patients are likely to benefit from any ALS (Advanced Life Support) providers. I will address that lack of critical judgment separately.
This is from a paper using video to review the quality of intubation with the documentation of the quality of intubation. It is not surprising that the actual quality was not as good as what was documented.
Humans are not good at memory. We document errors with a recall bias, but we pretend that this bias does not exist.
Figure 3.First-attempt success by physician type (nsubjects per type). “Attending” is comprised of both attending physicians from Pediatric Emergency Medicine and providers from Anesthesiology. First attempt success was 88% (6 of 7 subjects) for PEM attendings and 91% (10 of 11 subjects) for providers from Anesthesiology. Two study subjects, whose first attempts were performed by a neonatology fellow and an otolaryngology resident, respectively, are not included in this figure. 95% confidence intervals for the first attempt success of each physician type are indicated by the “error” lines: Attending (67%, 97%), PICU Fellow (40%, 89%), EM Resident (30%, 75%), PEM Fellow (25%, 64%), and Pediatric Resident (23%, 50%).[4]
The doctors at the top of the graph have the most experience. Those at the bottom have the least experience. If we want to determine the odds of successful intubation, we need to look at intubation experience.
Are we supposed to believe that experience has nothing to do with the success rates appearing in the graph?
A little detail about the actual experience of these doctors shows that they have about the same amount of experience as paramedics.
In trying to explain the difference between these results and the results from other studies of physician intubation and physician pediatric intubation, Dr. Green sees the primary point as the differences in the acuity of the patients and the differences in amount of experience available in a general ED as compared with a pediatric ED.
There are notable acuity differences between a general ED and a pediatric ED, with the latter demonstrating significantly fewer resuscitations and critical care procedures.8, 9 General emergency medicine residents perform an average of 146 intubations during their training,10 rendering them substantial comfort with the procedural sequence, equipment, anatomic features, techniques for endotracheal tube placement verification, and strategies for backup management.[5]
We don’t really want an inexperienced medic managing our child’s airway, but we demand less experienced medics. The fewer skills the medics perform, the less skilled they are.
The fewer procedures the doctors perform, the less skilled they are.
Pediatric emergency physicians, on the other hand, can learn and refine their ED intubation skills only on the rare children who require the procedure, and even at high-volume children’s hospital EDs, trainees are exposed to a low number of critically ill children.11 In a 2008 survey, pediatric emergency medicine fellows reported performing a median of 3.5 intubations per year, with some reporting that they performed zero.12 In a 2008 survey of pediatric ED directors, 62% reported that their volume of intubations was insufficient to maintain ongoing competency.13 [5]
The average number of intubations per medic per year was found to be 1 per year in Pennsylvania.[6] Pennsylvania does not require dual medics (some systems do use dual medics, but many do not). Pennsylvania also does not require responder-only paramedics on non-transport trucks as a way to dilute skill frequency even more. Some places are having not just 2, but half a dozen medics show up on calls.
This almost appears to be an attempt to prevent any medic from ever becoming experienced.
Why?
Some people pretend that being in the room while a patient is being intubated is the same as intubating the patient.
This study makes it clear that this is a lie. There are plenty of inexperienced doctors in the room, but they are still inexperienced.
This low-volume dilemma can be readily illustrated with data from the current article. The authors’ ED treated 90,000 children over the 12-month study period, during which there were 145 total intubations (of which 123 were rapid sequence).1 The program has 12 pediatric emergency medicine fellows, who performed just 21 of these intubations primarily. This averages to less than 2 intubations per fellow per year! During the fellows’ 3 years of training, they would average barely 5 total primary ED intubations.[5]
More than 1/4 of patients required 3 or more intubation attempts.
Skill dilution in action.
More medics equals more dilution of skills.
It is simple math. More medics available to perform the same number of skills means less experience.
How can any fellow become expert in such a setting? If techniques and strategies for managing difficult airways are not used frequently enough, they cannot be retained and effectively applied.[5]
Exactly.
Training and practice in difficult airway algorithms and rescue devices should be routine.[5]
Even if we do not have a medic in every seat, we should be regularly practicing airway management.
Before each shift, intubate Fred the Head 5 times in a row in less than 30 seconds each.
Before every shift.
That is silly of me. That is really only something that serious medics should do, not people who think that quantity is more important than quality.
When an airway must be secured, one must already know how to act, do it without hesitation, and have a well-thought-out backup plan should that first attempt fail. Action must be instinctive and reflexive but not mindless.[5]
Every week, we can practice a scenario of managing difficult airways.
Is this really too difficult?
Does a the tube automatically go in when enough paramedics are in the room?
Of course not.
Regardless, it suggests that a culture of command over airway management may not develop in locations with insufficient intubation volume.[5]
If we do not get enough tubes, we probably are not good at intubation.
The more medics the tubes are divided among, the worse we will be at intubation.
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Footnotes:
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[1] Allentown EMS will remain an all-paramedic squad
Rogue Medic
Sun, 19 Aug 2012
Article
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[2] I ignore it when NJ calls me a Semi-Medic, but it hurts when you point it out
Rogue Medic
Fri, 10 Aug 2012
Article
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[3] Long Beach Fire Department considers single paramedic response system
Rogue Medic
Thu, 09 Aug 2012
Article
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[4] Rapid sequence intubation for pediatric emergency patients: higher frequency of failed attempts and adverse effects found by video review.
Kerrey BT, Rinderknecht AS, Geis GL, Nigrovic LE, Mittiga MR.
Ann Emerg Med. 2012 Sep;60(3):251-9. Epub 2012 Mar 15.
PMID: 22424653 [PubMed – in process]
Free Full Text from Annals of Emergency Medicine.
There will probably be a podcast by David H. Newman, MD, and Ashley E. Shreves, MD. covering this paper, but the current issue podcasts usually do not get posted until a few weeks after the current issue. Annals Podcast page.
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[5] A is for airway: a pediatric emergency department challenge.
Green SM.
Ann Emerg Med. 2012 Sep;60(3):261-3. Epub 2012 Apr 19. No abstract available.
PMID: 22520991 [PubMed – in process]
Free Full Text from Annals of Emergency Medicine.
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[6] Procedural experience with out-of-hospital endotracheal intubation.
Wang HE, Kupas DF, Hostler D, Cooney R, Yealy DM, Lave JR.
Crit Care Med. 2005 Aug;33(8):1718-21.
PMID: 16096447 [PubMed – indexed for MEDLINE]
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Kerrey BT, Rinderknecht AS, Geis GL, Nigrovic LE, & Mittiga MR (2012). Rapid sequence intubation for pediatric emergency patients: higher frequency of failed attempts and adverse effects found by video review. Annals of emergency medicine, 60 (3), 251-9 PMID: 22424653
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Green SM (2012). A is for airway: a pediatric emergency department challenge. Annals of emergency medicine, 60 (3), 261-3 PMID: 22520991
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Check out the Henry Wang study in Annals last year that links paramedic experience with intubation and patient outcomes – not just intubation success.
Bob,
Out-of-hospital endotracheal intubation experience and patient outcomes.
Wang HE, Balasubramani GK, Cook LJ, Lave JR, Yealy DM.
Ann Emerg Med. 2010 Jun;55(6):527-537.e6. Epub 2010 Apr 14.
PMID: 20138400 [PubMed – indexed for MEDLINE]
Free Full Text from PubMed Central
I will get to that.
It raises some interesting questions –
Does unskilled intubation improve outcomes less than skilled intubation improves outcomes?
Does unskilled intubation harm outcome, while skilled intubation improves outcomes?
Does unskilled intubation harm outcomes more than skilled intubation harms outcomes?
Regardless, less experience leads to worse outcomes.
One of the problems is that there is so much evidence that I can’t include everything at once.
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